Doc probably owes me money after consistently charging me full price in office without checking with my insurance after my deductible was met and I only owed 20% because of coinsurance (BCBS, OHIO)

This is a very weird case, so I included a lot of context. There will be a table at the end of what I paid vs what I was actually responsible for.

I don’t know what context matters so I’ll do my best. I think I have really good insurance? My dad’s union has a trust fund that is managed by BCBS. My personal deductible of $800 was met mid September, I believe? The insurance guy I talked to said that I have coinsurance (?) and that means I don’t pay copays?

My first appointment with this office (7-18), they said they charge a flat rate up front. I told them then, that I had never had to pay upfront before and that I was sure that claims should go directly to the insurance. She did that wishy washy annoying kind of negotiation where she wasn’t sure, but she thought she should, but she would check, but she didn’t think she could contact their separate billing/bookkeeping company. It came across like she didn’t want to get in trouble for not making me pay, so she just charged a random $55.00 just because. I hate being badgered and I didn’t know for sure that she wasn’t right so I thought, “it sucks but I’ll pay it and bug them next time or whatever.”

Second appointment (8-8). My mother (who knows the ins and outs of our/my dad’s plan and worked in home insurance) tells me to be bold and say for sure that I should NOT be paying anything upfront. I put on my big girl pants, march in there, and “I’m not an expert, and I don’t know for sure, but I don’t think I’m supposed to pay you anything.” She said she checked with insurance and that my deductible had not been met and that I owed them for today and the left over for the last appointment, like $2xx. I tell her that I feel weird paying upfront again, and she agrees to only charge $140 for current appointment (their flat rate). She was also fielding calls between some other clients and their separate billing the whole time I was in the waiting room. I have no idea whether this mess was her fault or not. Like this lady might just be the operator/receptionist and not handle billing? I am certain that they are a small satellite location, but I have no idea if billing is done at their main office or if they can outsource it?

Third appointment (8-23) there is a new lady, she tells me that she’ll be there every time from now on. I’m assuming last lady got fired; she was very nice but I wasn’t surprised. New lady has that “professional” vibe, she seems to actually know what’s going on. However, she still says that I have to pay upfront. I say again that I don’t think I’m supposed to.

Now, at this point I will point out a misunderstanding on my end, I thought I had a copay until my deductible was met. So I was unassertive because I didn’t understand. My mom was saying (correctly, I think) that I never pay the dr. directly because we pay our “responsibility” to the insurance company (as I understood that conversation). I am also hearing from the dr. office that I owe a flat rate every time before they send the claim to insurance, and that it is the insurance company’s job to credit me whatever they covered (that I had already payed in the flat fee). I notice that this is weird, because literally all of my other dr. bills have come to me after they go to insurance. At this point though, I don’t know what a copay actually is (sorry) and I think that because this is a specialty dr, instead of my PCP, that somehow they have special rules for billing. I still feel kinda gross about it, so I ask her to check one more time that we haven’t met our deductible. She agrees to check with the insurance while I’m in my appointment.

( Another paragraph break because things get even weirder) So, I come out of my appointment and start chatting with her again. She says that my deductible is unmet. At this point she clarifies that we started a new coverage year July 1st. I think to myself, okay so this is one of those copay things I’ve heard about, and my mom’s totally just being dramatic about them committing fraud. She says that I owe the $140 upfront, in-office, today. Before I pay, I ask, “did you ever figure out the weird billing thing?” I explain to her the weird $55 and such. She looks up my account with their office. It has NO RECORDS and a $55 CREDIT! My last two visits had not been properly entered into the account, I guess? I tell her, that the $55 was from the first visit, and that I had paid $140 for my second visit. She gets a look on her face like, “what was my predecessor even thinking?” We agree that the situation is super weird, and I pay the $140 that day for my appointment and she agrees to figure out the mess.

I leave the appointment, my mom and I argue about whether or not I should have paid them. She is still arguing that it is an issue with the deductible, but has changed her tune to say that we have met our family deductible. Now, I continue to be confused, because my dad has had quite a few expensive surgeries this year, and we have paid a lot of his bills since July 1st. So, I also change my argument to, maybe the first few charges were before the family deductible was met and she needs to check with insurance to see which specific family bill pushed us over and which dates I should be getting our 80% 20% split. Meanwhile, my other drs are still sending their bills to insurance first, and they are paying a small amount on every bill. I have no idea why they are sending the bills differently and why the insurance is paying on them if our deductible hasn’t been met?

Fourth appointment (9-6). I have no clue what anything means any more. I go back to my assumption about the billing at this place being weird because they’re “special.” I pay my $140 bill, do my session, and then leave. Now, my mom paid for this session on her card. I forgot to ask for a receipt, and they never emailed me one like they usually do. So, not only is my mother mad that I paid $140 again, she is also mad that I didn’t get her a receipt. I talk her into going into the office with me to get things straightened out. We go in on a day that I don’t have an appointment. My mom asks about the deductible and tries to find out what the $140 is. She also talks to the receptionist about the billing and asks for a printed copy of my account/what we’ve paid. At this point we haven’t received anything from the insurance showing that they received the claims. The receptionist says that she can’t get it right then, but that she’ll have it either emailed to me, or she’ll have a paper copy the next time I come in. Great.

Fifth appointment (9-27). I did not receive an email, not even in my spam, and yes I looked twice. My mother has come into the office with me to talk to the receptionist. The receptionist does not have the printed copy. She says that we don’t have to pay anything at all. My mom doesn’t bat an eye because she was expecting that we would have met our out-of-pocket on account of my dad’s surgeries. She leaves and I do my appointment.

Since my last appointment(9-26—10-13). I went to an appointment with my regular dr. My PCP receptionist says in passing, “oh, you just met your deductible and you are only responsible for 20% for the rest of the year.” I kind of balk, we only just met my deductible? not the out-of-pocket? So, I am starting to worry about fraud again and resolve to call the insurance company myself. So, today I talked to the insurance guy. He says we have coinsurance and that means that I never pay in office. Bills should always go to the insurance first. He is very clear about this and repeats it with different wording a few times. I ask him if we have met our deductibles and/or our out-of-pocket. He says that my personal deductible ($800) has been met and that total I am at 900/2800 for my out-of-pocket. I didn’t write it down, but I believe our family deductible was met. Our family out-of-pocket is 3900/5600. Now, I don’t know what counts towards the deductible? Is it only what I’ve paid or is it everything I am responsible for? Anyways, I also asked the insurance guy for all of the claims and our responsibilities. The must have figured out the weird, because all the dates were at least represented (if not what I expected).

TLDR (if you’re into that sort of thing)

So, below is a table of what I paid vs what my responsibility was.

DatePaidResponsible forDifference (P-R)7-18$55$33.20 (don’t know why this isn’t higher?)$21.808-8$140$116.90$23.108-23$140$116.90$23.109-6 (deduct met)$140$23.38$116.629-27$0$23.38-$23.38Totals ->$475$313.75161.25

That isn’t an insignificant discrepancy in my eyes. I don’t know why the first responsibility isn’t $116? I think it is possible that the first appointment was 30 mins instead of an hour, but I don’t know if they bill by the half hour? It also makes me very uncomfortable that the receptionist didn’t break down why we didn’t have to pay on the 27th. I understand not disclosing that you owe someone money, before you have figured out how much. However, with everything else that has happened, I am very frustrated with the opacity of this place.

However, I don’t know what to do next. Should I:

A) Work directly with the mildly incompetent receptionist, despite everything.

B) Go above the receptionists head and contact the main offices and their billing?

C) Call my insurance so they start bugging the doctor’s office (I didn’t have my receipts when I called)

D) Lawyers? The IRS? Someone who audits medical professionals specifically?

E) Something completely different?

Also, with your recommendation, can you give me a course of action? Like, “work with the receptionist for 30 days and then look into legal recourse.” Or “your insurance has people to deal with this, just give them your receipts.” What if I get all of my receipts from the dr, and their files are still wrong? Is that a sign to contact appropriate authorities to see if they are doing this to other people? Do you think this situation is that serious?

Thank you for reading my looooooong post! I really appreciate any help you can give!